Provider Demographics
NPI:1063266716
Name:TOWN SQUARE HOSPICE ILLINOIS LLC
Entity type:Organization
Organization Name:TOWN SQUARE HOSPICE ILLINOIS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-588-3803
Mailing Address - Street 1:112 W WASHINGTON ST STE 2B
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-1668
Mailing Address - Country:US
Mailing Address - Phone:217-670-6990
Mailing Address - Fax:217-606-7938
Practice Address - Street 1:112 W WASHINGTON ST STE 2B
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-1668
Practice Address - Country:US
Practice Address - Phone:217-670-6990
Practice Address - Fax:217-606-7938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-17
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based